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HomeMy Public PortalAbout9075 EMPEROR AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT ,y0 CE-806 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or t r a certified copy thereof(Sec. 3800,Lab.C.) FOR APPLICANT TO FILL IN JOB � © Policy No. Company EACH NO. FEE /ADDRESS 76 New Residential Bldgs. &Pools Y� ❑ Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY Multi-family Sq. Ft. — NEAREST Certified copy is filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER OR FIRM NAMEQAl �y^ Date - Applicant Outlets: Rec._Light Sw. ADDR First 20 E 6� is/ i2'CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Z( d^ )1 A- Tel No. � � .772 COMPENSATION INSURANCE PLAN CHECK O (This section need not be completed if the work involved APPLICANT CL Lighting Fixtures First ADDRESS U by the permit is for. ioio nal � cc ' Total No. 0 I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. permit is issued, I shall not employ any person in any manner PERMIT tL so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT t1 Oven _ Dryer_W.M._ ADDRESS Cl) Z Date Applicant Top _ FAU _W.H., CITYTel No. Hood _ Fan —Other_ NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond.— LICENSE OR Exemption, you should become subject to the Workers' REG. NUMBER Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PR005,,SSED BY with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAR f deemed revoked. Up to 1 Incl. FINAL LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE /) VALIDATION Over 10 to 50 Incl. 6f- I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. BY AL 19'(commencing with Section 7000) of Division 3 of the Busi- Over 100 �— ness and Professions.Code, and my license is in full force and effect. Services 0-200 Amp. Under 600 V License Number Lic. Class 201-1000 Amp. Under 600 V Contractor Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances �D Sign with One Branch Circuit I hereby affirm that I am exempt from'the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): Misc.Conduits&Conductors I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— _4 0 R 6 A structure is not intended or offered for sale (Section 7044, Business and Professions Code). # o o,o o o 2 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 2 -'o 1 7.0 0 for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued(Sec. 3097,Civ.C.). o 0 0 1 �],0 Q'0 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 021 7'-81 Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE above information is correct.I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to.enter upon the above-mentioned y for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date r WORKERS' COMPENSATION DECLARATION CE 806G 10/81 APPLICATION FOR ELECTRICAL PERMIT ,�.,•a`h�ie�y affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY'a or .certified copy thereof (Sec. 3800, Lob. C. Policy No. Company LL IN JOB FOR APPLICANT TO FILL [NO FEE ADDRESS,*30,7 r�y,r Certified copy is hereby furnished. New Residential Bldgs. & Pools 1 &2-Family, S Ft. $ $ LOCALITY wr �J Certified copy is filed with'the county building i spec y Q tion department. Multi-family Sq. Ft. Dater+X6g&_A lica Residential Swimming Pools OWNER OR PP FIRM NAME CERTIFICATE OF EXEM ION FROM WORKERS' Outlets: Rec_7—Light3Sw.a__.. MAIL COMPENSATION INSURANCE ADDRESS S (This be completed if the work involved b y2 First 20 ( s section neenot p Y Total No._� Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT `✓/{ Oc-i'7 permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS V&-7 Total Na. .49� Additional CITY TCm j-{ Tel. No..2e�c� cy Date Applicant C�lr` PP Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT c Exemption, you should become subject to the Workers' Range_ Heater_D.W. Compensation provisions of the Labor Code, you must forth- Oven _ Dryer —W.M.— ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood Fan _Other_ CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER '4 f,7 /_ —— Class. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCE E BY .and Professions Code,and m license is in full force and effect, Power Apparatus& Large Appliances /' y 57 (/Size & Type HP, KW, KVA, or KVAR' License Number+S/ S L6' Lic. Class Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE f VALIDA&N Contractord✓4l✓ �itici �vi ate f` Over 10 to 50 Incl. ❑ FINAL I am exempt under Sec. Over 50 to 100 Inc. BY UA B.&P.C. for this reason Over 100 Services, Swbd., MCC& Panelboards Date: 0 -200 Amp. Under 600 V_ Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V 1 1 '�4 A Exemption for Reg. Mainz. Elect. c SINGLE FAMILY Temp. Power Pole& Appurtenances # o o o 0 0 2 'HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit. I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits 1 - 2 2 Z 50 Law for the following reason (Section 7031.5, Business and Professions Code): 0 0 0 2 2 5 0 6 ❑ .I, as owner of the property, will do the work and the Misc. Conduits Conductors .1 1.2.8—84 structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— , 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the TOTALFEE G above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date _ WORKERS'COMPENSATION DECLARATION CE 806G (2-80) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) FOR APPLICANT TO FILL IN JOB Policy No. Company Y. q• EACH NO. FEE ADDRESS ® 7� New Residential Bldgs.&Pools Certified copy is hereby furnished. 1 &2-Famil S Ft. $ 'OZS — $ LOCALITY �r�� e F1Multi-family Sq. Ft. — NEAREST ��� Certified copy is filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER OR FIRM NAME Date Applicant Outlets: Rec._Light Sw. MAIL ®� First 20 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY RIL4,P1 * Tel No. COMPENSATION INSURANCE PLAN CHECK ��p } APPLICANT '�U a (This section need not be completed if the work involved O by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS U Total No. Additional I certify that in the performance of the work for which thisFixed Appliances Not Over 1 HP CITY Tel No. 0 permit is issued, I shall not employ any person in any manner PERMIT so as to become subject to the Workers' Compensation Laws. Range_ Heater—D.W. _ APPLICANT 451414 � W Oven _ Dryer_W.M. LIDDRESS Cn fpplicant Top _ FAU _W.H.._ / Z Hood•_ Fan _OtherCITY Tel No.(Date OTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond.— LICENSE OR /�� o Exemption, you should become subject to the Workers' ]REG. NUMBER "7,6 Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCES ED BY with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR .5— deemed revoked. Up to 1 Incl. . Over 1 to 10 Incl. DATE L LICENSED CONTRACTORS DECLARATION �r VALIDATION Over 10 to 50 Incl. (hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY Hess and Professions.Code, and my license is in full force and Ir(/ effect. Services / License Numbe e Lic. Class r 0-200 Amp. Under 600 V t;e, 201-1000 Amp. Under 600 V Contracto Date Over 1000 Amp.or Over 600 V WO/ME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit �'4 6 5 5 A License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits _ ness and Professions Code): # o'0 0 0 o 2 Misc.Conduits&Conductors " ❑ I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 2 -'o 5 6 1 2 structure is not intended or offered for sale (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY o,o a 5 6 2 v I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued (Sec. 3097,Civ.C.). `2 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives f this County to enter upon the above- ntioned prope r nsp ion purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE Si ature of Permittee Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1201310001 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL IDILE FEES PAID BUILDING ADDRESS: 1 9075 EMPEROR AV 1FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 SGAB CA 917752016 1 ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: 15382-012-037 1A1 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: H1 LOCALITY: TEMPLE CITY, Cl IG1 OUTLETS-LGT,SW,RECP 1.00 OUT 1.90 1 (TENANT: 1G2 LIGHTING FIXTURES 26.00 LGT 47.00 (ISSUED ON: PROCESSED BY: PLAN BY: I IH4 RES RANGE HDS LT 3HP 1.00 HOO 10.90 101/31/12 SR I IH5 RES WASH MACH LT 3HP 1.00 WAS 10.90 1 (OWNER: TEL. NO: 1 TOTAL FEES 98.50 1FINAL DATE FIN BY: CODE: 1 ICHENG, PAUL (626) 372-9180- 1 1 19075 EMPEROR AV ISGAB 917752016 1 IDD SSCRIPTION OF WORK 1 I I (INSTALL 23 RECESSED LIGHTS, REPLACE 3 LIGHT FIXTURES AND 1 i I ISWITCH, RANGE HOOD AND WASHING MACHINE 1 1APPLICANT: TEL. NO: 1 ISAME AS OWNER I 1 1SPECIAL CONDITIONS: I I I I I ICONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE ISAME AS OWNER - I I I LIC. NO ITEMPORARY POWER POLE I I I I I 1UNDERGROUND CONDUIT I I - I (ARCHITECT OR ENGINEER: TEL. NO: i 1UFER GROUND I I 1 I I I 1 I 1 LIC. NO: 1ROUGH CONDUIT I I I I I I TROUGH WIRING 1 I 1MAIN WATER LINE I I I 1PLASTIC Y/N METAL Y/N I I I I 1 1UTILITY COMPANY NOTIFIEDI I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I IREPORT ID: DPR265 ROUTE TO: BS0508 1 1 I I I I